【作者】 程洁敏；

【导师】 颜志平；

【作者基本信息】 复旦大学 ， 影像医学与核医学， 2008， 硕士

【摘要】 第一部分肝癌TACE后存活5年以上病例DSA和CT分析目的:回顾性分析肝癌TACE治疗后存活五年以上和一年以内病例的DSA和CT表现。重点分析DSA造影片和CT片中肿瘤病灶的大小、数目、病灶染色表现、血供丰富与否、参与血供的靶血管情况、动静脉瘘情况、静脉内癌栓情况、碘化油在肿瘤内的沉积情况,总结他们各自的cT和DSA表现特点,以期为临床判断预后提供有价值的信息。材料和方法:收集首次TACE治疗后存活五年以上肝癌病人104人作为观察组,首次TACE治疗时年龄24-80岁,平均56岁。男性93人,女性11人。其中69例病人由手术(65例)或穿刺(4例)得到病理诊断。65例为肝细胞肝癌,2例为混合细胞性,2例为胆管细胞癌,其余病例为临床诊断。另收集同期进行TACE治疗,生存一年以内肝癌病例52例,作为对照组。首次TACE治疗时年龄17-72岁,平均51岁。男性45人,女性7人。其中14例病人有手术病理或穿刺病理证实为肝细胞肝癌,其余病例为临床诊断。两组病人的介入治疗方法均为以TACE为主的综合治疗。其中TACE时选用碘化油和明胶海绵作为栓塞剂。碘化油用量依病灶大小、肝功能情况及DSA显示有无动静脉瘘及有无静脉内癌栓决定。分析两组病例DSA造影片及CT片。重点分析肿瘤病灶的大小、数目、病灶染色表现、血供丰富与否、参与血供的靶血管情况、动静脉瘘情况、静脉内癌栓情况、碘化油在肿瘤内的沉积情况。结果:观察组中,最短生存期5年,最长15年以上,至今存活。59例病人为手术后复发病人,14例病人接受过二次手术,6例病人TACE治疗过程中接受过Ⅱ期手术或肝移植治疗。TACE治疗次数最多18次,最少4次。两次TACE手术间隔最短6周,最长4年。末次TACE至存活最长8年。首次TACE治疗时单个病灶直径最大15cm,最小1cm。多个病灶最多7个,累加直径16cm。各肝叶均有分布。病灶均为富血供,未见明显的动静脉瘘。门静脉主干及肝静脉2级分支内均无癌栓。首次TACE时病灶单支血供83例,多支(2支或以上)21例。末次TACE时单支血供57例,多支血供47例。所有病例均有过CT显示碘油病灶内沉积良好时期。6.7%(7/104)病例有肿瘤所在肝段萎缩表现,7.7%(8/104)病例有胆汁瘤样改变出现;对照组中,最短生存划4月,最长12月,13例病人为手术后复发病人,无Ⅱ期手术切除病例。T A C E治疗次数最多6次,最少1次。两次T A C E手术间隔最短1月,最长3月。首次T A C E治疗时单个病灶直径最大25cm,最小12cm;病灶多发者中最多者呈弥漫分布难以计数,累加病灶占据肝脏体积的70%左右。病灶各叶均有分布,均为富血供,59.6%(31/52)病例有明显的动静脉瘘。48.1%(25/25)病例门静脉内有癌栓。15.4%(8/52)病例肝静脉内有癌栓。首次T AC E时病灶单支血供39例,多支血供13例。末次T A C E时单支血供35例,多支血供17例。14例病例有过DSA下显示碘油沉积较好,仅3例有过CT显示病灶内碘油沉积良好阶段。无一病例有肿瘤所在肝段萎缩和胆汁瘤样改变出现。结论:T A C E治疗后存活5年以上病例的DSA和CT与存活1年以内病例相对比,其特点为:长期生存者的病灶相对较小(单个病灶直径最大15cm,多个病灶累加直径最大16cm)。没有明显的动静脉瘘和静脉内癌栓,CT显示病灶内碘油沉积良好,部分病例有肿瘤所在肝段萎缩或出现胆汁瘤样改变。肝脏肿瘤供血动脉随TA C E治疗次数增多而逐渐纤细,如有病灶存活,往往有侧支供血出现。第二部分肝癌TACE治疗后存活5年以上病例临床相关因素观察目的:回顾性分析肝癌TACE治疗后存活五年以上病例的临床相关因素,并和同期生存时间不满一年的肝癌患者进行对照,探讨影响TACE长期疗效的因素,以期客观评估TACE治疗和其他治疗方法的联合应用价值。材料和方法:收集首次TACE治疗后存活五年以上肝癌病人62例作为观察组。男性53人,女性9人。首次TACE治疗时年龄24-80岁,平均58岁。其中39例得到病理诊断,23例为临床诊断。观察组病例中,首次TACE治疗前均有不同程度的肝硬化,肝功能按Child-Pugh分级,A级45例,B级17例。治疗前均无血行和淋巴系统远处转移。38例病人首次治疗前AFP＞400ng/ml.24例病人首次治疗前AFP＜400ng/ml.另收集同期进行TACE治疗,生存一年以内肝癌病例52例作为对照组。首次TACE治疗时年龄17-72岁,平均51岁。男性45人,女性7人。其中14例病人得到病理珍断为肝细胞肝癌,其余病例为临床诊断。34例病人首次治疗前AFP＞400ng/ml.18例病人首次治疗前AFP＜400ng/ml.52例对照组组病例中,首次TACE治疗前均有不同程度的肝硬化,肝功能按Child-Pugh分级,A级25例,B级27例。治疗前均无血行和淋巴系统远处转移。肝癌分期:观察组属Ⅰ期24例,Ⅱa期26例,Ⅱb期12例(Ⅱa期前占80.6%,50/62);对照组属Ⅱb期27例,Ⅲ期25例(Ⅱb后病例为100%,52/52)。两组病人的介入治疗方法均为以TACE为主的综合治疗。分析两者病例各自的TACE术前的基础肝功能情况,肿瘤的临床分期、TACE术中的肝功能保护、TACE的次数和间隔、碘化油用量和方法、动静脉瘘和门静脉癌栓的处理、肝内转移和远处转移灶出现的情况、伴发病变的介入处理、TACE和其他治疗方法的联合应用。结果:观察组中,生存期5年者26例,6年以上者36例。对照组中,最短生存期4月,最长12月。两组病人的临床分期有差异(P＜0.05),观察组的病人Ⅰ期及Ⅱa期居多;对照组的病例以Ⅱb期及Ⅲ期为主。观察组中首次TACE治疗前AFP阳性者38例,治疗后有34例AFP下降至正常;对照组AFP阳性者34例,治疗后,仅有8例转阴。观察组中TACE治疗次数最多18次,最少4次。两次TACE手术间隔最短6周,最长4年。对照组中TACE治疗次数最多6次,最少1次。两次TACE手术间隔最短1月,最长3月。观察组中首次TACE治疗时单个病灶直径最大15cm;多个病灶最多7个,累加直径16cm。各肝叶均有分布。未见明显的动静脉瘘,门静脉主干及肝静脉2级分支内均无癌栓。对照组中首次TACE治疗时单个病灶直径最大25cm,最小12cm;病灶多发者中最多者呈弥漫分布难以计数,累加占居肝脏体积的70%左右。各肝叶均有分布。59.6%病例有动静脉瘘,48.1%病例门静脉内有癌栓。观察组中有40.3%病人采用单纯TACE治疗模式,55.8%病人采用TACE联合其他治疗。对照组中有78.8%病人采用单纯TACE治疗模式,21.2%病人采用TACE联合其他治疗。两组采取综合治疗的病人比例差异无统计学意义(P＞0.05)。观察组有45.2%病人有肝内新病灶产生,33.9%病人有远处转移。对照组中有92.3%病人有肝内病灶未得到控制而继续增大。19.2%有远处转移。两组病人的远处转移的发生率有统计学意义(P＜0.05)。结论:TACE治疗后存活5年以上病例的临床相关因素与存活1年以内病例相对比,其临床特点为:长期生存者的肝癌的病灶相对较小,临床分期为Ⅱa期以前的占80.6%,没有Ⅲ期的病人;肝功能较好,分级为Child-Pugh A或B级;AFP经TACE治疗后转阴率高。没有明显的动静脉瘘和静脉内癌栓。治疗上的特点为TACE时除对肿瘤作化疗栓塞外,尽可能保护肝功能。TACE后采取综合治疗,保护肝功能,尽可能延长2次TACE手术的间隔时间。更多还原

【Abstract】 Part I Observation of the image of CT and DSA in the patients with HCC who were survived more then 5 years after treated by TACEObjective: To observe the CT findings and the image of DSA in the patients with PLC who were survived more than 5 years after treated by TACE .Materials and Methods : 104 patients of PLC (primary liver cancer) who were survived more than 5 years after treated by TACE were collected as a trial group. The age were 24-80 years old when the first TACE was done, average is 56 years old. Male was 93 and female was 11. There were 65 cases diagnosed as hepatocellular carcinoma, 2 cases diagnosed as cholangiocarcinoma, 2 cases diagnosed as cholangiohepatocellular carcinoma by the pathology. Others diagnosed as hepatocellular carcinoma by the clinical diagnosis. Another 52 cases of PLC who were survived less than 1 year after treated by TACE were collected as a contrast group. The age were 17-72 years old when the first TACE was done, average is 51 years old. Male was 45 and female was 7. There were 14 cases diagnosed as hepatocellular carcinoma by the pathology. Others diagnosed as hepatocellular carcinoma by the clinical diagnosis. The main therapy was TACE plus PEI, RFA, radiotherapy and so on in the two groups. The CT findings and the image of DSA were be analysed.Results: In the trial group, the longest survived time were more than 15 years and the patient still lived well so far. 59 cases were recurrent hepatocellular carcinoma after surgery. 14 cases were get second surgery, 6 cases got second phase surgery in the period of interventional radiology. The number of the TACE is 4-18 times. The period time of the two TACE is between 6 weeks to 4 years. The longest one from the latest TACE to survived time is 8 years. The largest diameter of the single tumor is 15 cm. The cumulated total diameter of the multiple tumors is 16 cm. All tumors were abundant with blood supply. There was no obvious A-V short in the tumor. The blood supply of the tumor is single branch in 83 cases, multiple branches in 21 cases when the first TACE was done. But in the end of the TACE the blood supply of the tumor is single branch in 57 cases, multiple ones in 47 cases. All the cases had the period that the tumor was full filled with lipiodol. 7 cases showed there was atrophy in the section of the liver where the tumor located. 8 cases biloma occurs. In the contrast group, the longest survived time was 1 year. 13 cases were recurrent hepatocellular carcinoma after surgery. No case got second phase surgery. The number of the TACE is 1-6 times. The period time of the two TACE was between 1 to 3 months. The largest diameter of the single tumor is 25 cm. There was obvious A-V short in the 31 cases, portal vein embolism in the 25 cases. The blood supply of the tumor is single branch in 39 cases, multiple ones in 13 cases when the first TACE was done. But in the end of the TACE the blood supply of the tumor is single branch in 35 cases, the multiple one in 17cases. Only 3 cases had the period that the tumor was full filled with lipiodol on the CT scan view. There were no cases showed atrophy in the section of the liver and no biloma occurs.Conclusion: The characteristic of the CT findings and the DSA images in the patients with PLC who were survived more than 5 years after treated by TACE are: smaller tumor, no A-V short, no embolism in the vein, full filled of lipiodol in the tumor. Some cases got atrophy in the section of the liver where the tumor located. Some cases biloma occurs.Part II Observation study of clinical correlative factor in the patients with HCC who were survived more then 5 years after treated by TACEObjective: To observe the clinical correlative factor in the patients ill with HCC who were survived more then 5 years after treated by TACE.Materials and Methods : 62 patients of PLC (primary liver cancer) who were survived more than 5 years after treated by TACE were collected as a trial group. The age were 24-80 years old when the first TACE was done, average is 58 years old. Male was 53 and female was 9. There were 39 cases diagnosed by the pathology. Others diagnosed by the clinical. There were varies cirrohis in all cases before first TACE. The liver function was Class A Child-pugh in 45 cases. Class B in 17 cases. No class C patient in this group. There was no metastasis tumor in the other part of the body before the first time of the TACE. Another 52 cases of PLC who were survived less than 1 year after treated by TACE were collected as a contrast group. The age were 17-72 years old when the first TACE was done, average is 51 years old. Male was 45 and female was 7. There were 14 cases diagnosed as hepatocellular carcinoma by the pathology. Others diagnosed as hepatocellular carcinoma by the clinical diagnosis. There were varies cirrohis in all cases before first TACE. The liver function was Child-pugh class A in the 25 cases, Child-pugh class B in the 27 cases. No class C patients, too. There was no metastasis tumor in the other part of the body before the first time of the TACE. 24 cases belong to I stage, 26 cases belong to IIa stage and 12 cases belong to IIb stage in the trial group. 27 cases belong to IIb stage, 25cases belong to III stage in the contrast group. The main therapy was TACE plus PEI, RFA, radiotherapy and so on in the two groups. The liver function, clinical stage of the tumor, the time number and the separate time of the TACE, the dose of the lopiodol and so on were analysed.Results: In the trial group, 26 cases got survived more than 5 years and 36 patients got survived more than 6 years. In the contrast group, the longest survived time was 1 year. There was obvious difference between 2 groups in the clinical stage (P<0.05). Almost 80% cases were II stage in the trail group. Almost 70% cases were III stage in the contrast group. AFP positive cases turns to negative about 34/38 in the trail group, only 8/34 cases turns to negative in contrast group. In the trail group, the number of the TACE is 4-18 times. The period time of the two TACE is between 6 weeks to 4 years. The longest one from the latest TACE to survived time is 8 years. The largest diameter of the single tumor is 15 cm. The cumulated total diameter of the multiple tumors is 16 cm. All tumors were abundant with blood supply. There was no obvious A-V short in the tumor. While in the contrast group, the number of the TACE is 1-6 times. The period time of the two TACE was between 1 to 3 months. The largest diameter of the single tumor is 25 cm. There was obvious A-V short in the 31 cases, portal vein embolism in the 25 cases. In the trail group, there was 45.2% cases got recover hepatocellular carcinoma in the hepatic lobe and 33.9% cases got metastasis tumor in the other organ of the body. Metastasis tumor almost occurs on the 3 years later after first TACE. While in the contrast group, 10 cases (19.2%, 10/52) got metastasis tumor in the lung.Conclusion: The characteristic of the clinical correlative factor in the patients with PLC who were survived more than 5 years after treated by TACE are: smaller tumor,early clinical stage of the tumour, liver function in Class A or Class B, AFP positive canturns to negative and kept a long period of the time. The protection of the liverfunction was very important while the TACE procedure were be done.更多还原